Application for Internship in Agency of Employment BA & MSWII: Due second Friday in April MSWI: Due second Friday in June I. Identifying Information: Student Name: Field Level: II. Date: BA MSWI (check one) MSWII Academic year of placement: Present Job Assignment: A. Please type in the text box below a description of your present job assignment and the specific circumstances of the assignment. Include: • Job classification • Job status (temporary/permanent; full time/part time); specify that probationary status in current work assignment has been satisfactory completed. • Length of employment • Regular hours of employment • Present job duties and a thorough description of functional tasks • Names of those persons responsible for your direct supervision and for administration of the agency. 1 III. Prior Experiences A. If you have worked in other areas of the agency in addition to your present job assignment, include in the textbox below, a brief description of those areas/units and the length of time in each, including months and dates. If applicable, identify the unit and/or agency where you have had a prior BA and/or MSW level internship. Provide a brief description of the internship experience, roles undertaken, and skills learned. IV. Proposed Internship Experience A. Please type in the text box below a written description of the proposed field placement assignment and the specific circumstances of the proposed internship. Note: The proposed internship must be clearly differentiated from current and past job assignments and must meet the curriculum requirements of the social work program. Include the following: • Proposed assignment (i.e. area or unit) • Proposed work and internship days and hours, including planned workload modification to accommodate internship hours. Also address how you will accommodate required classes and any program seminars (Note: Consejo and Title IV-E seminars do not count toward field hours). Field (MSW) and supervision seminars (BA) do count toward field. 2 B. Proposed MSW Field Instructor: Please provide the name of the proposed MSW field Instructor who has no authority over you as an employee. Field Instructor Name: Title: Email: Phone: If the field instructor is new to Fresno State, attach a Field Instructor Profile form to this application. The form can be found on the DSWE website at: http://www.fresnostate.edu/chhs/social-work/policiesforms/fieldmaterials.html C. Proposed Learning Assignments: Refer to the Field Manual for your field level (BA, MSWI or MSWII) located on the DSWE website. Look up the learning agreements and specify proposed assignments tailored to your proposed internship that meet curriculum requirements specified in the learning agreements. Professional Identity/Development (list at least 4 activities) Professional Ethics- BA only (list at least 3 activities) 3 Generalist Practice (BA) or Multi-Systems Practice (MSWI & MSWII) (list at least 5 activities) Evaluation Practice (list at least 3 activities) The signatures below indicate agreement with the terms of this proposal and an understanding that the arrangements agreed upon may not be changed without advanced approval from both the agency and the Field Coordinator. V. Signatures: ___________________________________________________________ ______________________________ Student Signature Date: ___________________________________________________________ ______________________________ Proposed MSW Field Instructor Date: ___________________________________________________________ ______________________________ Agency Administrator Date: ___________________________________________________________ ______________________________ Department of Social Work Field Coordinator Date: 4